The Great L&D/PP Divide: AKA, Bikers vs. Puritans

Wow, what a very long time it’s been since I last managed to post!

Let’s just say business has been good and I’ve been preoccupied with delivering babies over the past few months.  Unfortunately, that has precluded me from writing as much as I’d like to.  It has, on the other hand, given me a lot to write about!

So let’s talk about a phenomenon that is pretty much universal in inpatient OB nursing…the difference between L&D and postpartum (PP) nurses.

If you work on a unit like mine where L&D and PP are split, it is easy to spot the personality differences between L&D and PP staff, and sometimes, this difference can cause a bit of a rift between the units as a whole.

Puritans and Bikers 1 PNG

Generally speaking, the beef that each side has with the other is due to the basic functions of L&D nurses vs PP nurses and the differences in personality that often coincide with each sub-specialty.

The Postpartum Nurse through the eyes of the L&D Nurse

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A PP nurse tends to stick to a schedule and a well-laid plan, sometimes to the point of seeming inflexible.  One might say they’re sticklers for tradition (cue the Fiddler on the Roof music!).  Nevertheless, this down-to-the-minute timing is important.  They often have 3-4 couplets (moms and babies) to care for, scheduled and PRN medications to keep up with, and round-the-clock teaching, especially for new moms and dads, to contend with at all hours of the day and night.  So on that note, it’s no wonder you’d think someone spit in their cheerios when you ask them to take a fresh C-section patient in the middle of their midday assessments.

PP nurses also have the added responsibility of helping parents establish a pattern for feeding, sleeping and caring for baby, which ideally begins to take root before baby goes home.  PP nurses try to maintain some semblance of a routine so that when mom and dad are cut loose with baby in a few days, they aren’t left floundering at home, wondering how the heck they’ll ever survive without Nurse Annie rounding on them every hour.

Now, keep in mind this isn’t every PP nurse, but some carry the “it must be done my way at precisely this time” attitude beyond the point of reason.  Thankfully, the vast majority can ignore the subtle, insignificant differences in practice amongst their colleagues and adapt to the changes as they come. It’s the ones who can’t move past the fact that the L&D nurse told them the baby’s weight before their APGAR scores in report with whom you’ll most often see trouble.

The L&D Nurse through the eyes of the Postpartum Nurse

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L&D nurses typically enjoy being busy.  They are adrenaline junkies in hiding.  Unlike the ER nurse, who wears her love for the rush of a trauma on her sleeve, L&D nurses quietly thrive on the occasional thrill of the unexpected–a prolapsed cord, a crash C-section, a laboring woman who comes through triage dilated to 10cm at 1am screaming for Jesus and stopping 2 feet short of her delivery room to push out a baby in the middle of the hall–y’know, that kind of thing.

As such, L&D nurses can be perceived as disorganized, harried, rowdy, rude/outspoken, and at times, even a little bit crazy.  While I’ll give you a bit of room on that last descriptor, disorganized and harried aren’t common traits of L&D nurses…at least, not good ones (and trust me, it’s usually very obvious very quickly if an orientee can’t roll with the punches in the heat of a delivery).  Because there can be so much chaos inherent in our jobs, a good L&D nurse keeps a level head no matter what is going on.  She is likely very organized, but not off-put if she doesn’t have time to dot her i’s and cross her t’s.

As for rowdy, rude, and outspoken…again, the very nature of L&D nursing is likely to attract a more lively crowd, so don’t be too surprised if you hear your L&D nurse swear under her breath at the **** IV pole as she’s trying to prime her pitocin line as her patient is swearing at the doctor, the doctor is yelling at the surg tech, the surg tech is yelling at the nurse, and the nurse is venting her frustration on the technological advances of modern medicine.

As long as the charting is done, her report sheet is (relatively) complete, and her patients are alive and well, your L&D nurse is a happy nurse.

The Bottom Line

It’s a pretty straightforward one…L&D nurses are different from PP nurses, and for a very good reason.  If you work on an LDRP unit where L&D and PP aren’t separate, see if you can pick out the differences between those coworkers who prefer to care for the laboring and those who tend to prefer postpartum patients.

At any rate, those with strong skills in either department are indispensable assets to mothers and babies.  Because if you ask any given L&D nurse and any given PP nurse if they want to trade places for the day, your answer will invariably be…

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Or, in the vernacular…”NO!”

 

That Awkward Moment When…

I know.  There are a lot of awkward moments in my job.  So I’ll be quick to clarify.

That awkward moment when…you save someone’s life and no one else* knows it.
(This does not include the responding nurses/physician!)

I had my first postpartum hemorrhage the other day.  It was terrifying.  Again, I don’t tell you that as a new nurse whose experience barely extends beyond the imaginative, scenario-based world of training.  And while the scene was unforgettable–arguably, indescribable, as after several edits, I still don’t feel I’ve captured the full chaos of the situation–one thing will always stick with me.

I was the only one who realized what was going on.

I’ll set the stage for you.  I’m about at the end of a recovery after a fairly difficult vaginal delivery.  The patient is doing fine.  Baby is doing fine.  The mom has some visitors in her room and they’re casually chatting while I’m giving her some pain medication.  However, as I’m pushing the med, the patient starts to feel sick.  I hand her a bucket and she is very clearly nauseated, retching but unable to produce anything.  I think to myself, perhaps she’s simply naïve to narcotics.  That could be the case.  Some folks are extremely sensitive to narcs and will become sick quickly after an IV push.  However, it was just as I was starting to think that this was pretty intense to be a reaction to a narcotic, it happened–

A loud splash, as if someone had thrown a bucket of water on the floor.  I look down to see the biggest puddle of red I’ve ever seen creeping rapidly toward my shoes.  And then, a family member’s reaction so misplaced, I can barely believe what I’m hearing…

Hemorrhage 1

Now, let me pause here to explain to you how delivery beds are made.  They have a bucket underneath them that is specifically designed to catch blood during a delivery.  That bucket was in the path of this gush.  Delivery beds aren’t thin, either, meaning there is a lot of distance, including mattress and metal pieces, to travel through in order to reach the floor.  That’s a lot of stuff between the patient and the floor–plenty of material to slow down a fluid spill.  For blood to have hit the floor hard enough to splash…wow.  That’s a lot of blood.

All of this crossed my mind in the span of a few milliseconds before I reached for my poor patient’s boggy uterus and hit the emergency bells.

Hemorrhage 2

If, by some strange coincidence, you realize as you read this that you were among the family members who were sitting in the room when this happened, I really didn’t mean to be rude.  Let’s just say I was stunned–flabbergast–appalled at the thought that you were sitting at bedside during a massive postpartum hemorrhage and laughing as your family member was bleeding to death.

Don’t get me wrong: I don’t expect those guests to be medical experts.  But there is something strange and unsettling about people who laugh at of a volume of blood that is rarely shown in appropriate circumstances on TV, much less seen in a real-life situation involving a loved one.  I argue not for the medical proficiency of her guests, as this was not necessary to deduce that serious trouble was amiss.  Rather, there was a sickening lack of basic concern for the crimson pool that grew by the second and the simultaneously dwindling consciousness of the woman in bed.

At any rate, after an initial moment of stunned silence, the family members left the room, and in a matter of seconds, the cavalry arrived.  The patient was barely conscious, her blood pressure so low that the machine couldn’t read it.  I had pulled back the blankets to reveal a pool of blood in the bed, soaking the mattress and sheets from foot to waist.  One nurse was starting a large bore IV while another opened up the pitocin and fluids that were already running, infusing them in at full blast.  Another nurse put an oxygen mask over my patient just as the doc came running in, slid a hand into my patient’s uterus and pulled out some of the biggest clots I’ve ever seen.

In all, we estimated somewhere around 2.5 liters of blood lost in less than a minute.  Really, 2.5 liters.  Consider that te average human adult has somewhere in the neighborhood of 5 liters of blood circulating.  Approximately half of my patient’s blood had exsanguinated and now lay in the bed or on the floor.

After stabilizing my patient and cleaning up the veritable mess that remained, we let the visitors back in at her request.  I felt bad for the poor girl.  She had been up for over 24 hours, had gone through hell in labor, and now looked like death warmed over (and that is no exaggeration).  Her blood levels, even on the CBC immediately after the bleed, were low.  I expected she’d receive a blood transfusion before my shift was up.

But when her visitors came marching back in, to my amazement, they seemed to have forgotten the events that led to their abrupt eviction and instead, peppered my patient with comments like this:

Hemorrhage 3

Hemorrhage 4

I know what you’re thinking.  They’re probably just being nice, you’ll say.  They’re probably trying to make her feel better, you reason.

No.

Simply put, no.

I only wish their reaction could be attributed to some benevolent desire to make this patient feel like less of a train wreck than she was.  In fact, I made every effort to believe they were only being nice until I was eventually confronted by the uncomfortable facts: they were nothing short of completely sincere.

To boot, even my patient didn’t seem to understand the fact that she had done the Texas two-step with death that night and come out on top, even when I explained to her the extent of her bleeding, the meaning of her CBC results, and the fact that she might get blood to prevent spontaneous bleeds that could result from extremely low blood counts.

So it was an odd night to say the least.  I headed home feeling a bit off, knowing that I had done something incredible, but with very little acknowledgement.  It’s happened before, and I know it will happen again.  It’s just strange to be the one who experiences it in full: the crash in vital signs, the blood, the near-fatality, the incredible response of the staff…

…and to go from all that adrenaline, action and real-life heroism to a patient and family whose biggest concern is…when the mom can have something to eat.

However, as one of my more thoughtful coworkers pointed out, maybe it’s better that way.

The Happiest Job On Earth

Somewhere between the shampoo and conditioning experience of my haircut a few days back, I mentioned to Anna, my hairdresser, that I am an L&D nurse.

“Ohhhh, you’re so lucky! I’ll bet you have the happiest job on earth!” She cooed.

“Well, kinda…” I trailed off, realizing that I was in a salon full of nice-looking ladies who probably didn’t want to hear about the ugly side of my work.

“Well, I’m sure it has its downsides, but you spend your whole shift holding babies, right?”

“Actually, Anna, babies are only on my floor two hours before I send them to postpartum.” I said, not even bothering to foray into the real meat and potatoes of just why L&D nursing isn’t what practically everyone who isn’t an L&D nurse seems to think it is.

I left my haircut exceedingly happy with my new look, but a bit rubbed by Anna’s faulty yet common opinion of my profession.  And then I realized–Cervix With a Smile!  What better place to write an expose on the real ins and outs of L&D nursing?

This post is admittedly geared toward nurses who are interested in L&D, but really, it applies to anyone, especially if you think my shift is entirely comprised of baby powder and cute little outfits with a Johnson & Johnson “Nurses Heal” ambiance and slow string music.  As an aside, if you know a postpartum, pediatric, PICU or NICU nurse, many of the below points also apply to their work.

So here we go, folks.  Take a walk in my plastic wipe-able clogs and see what L&D looks like from my side of the bed.

Why L&D Nursing isn’t what you think it is:

  1. I’m a professional.
    When you walk into your friend/family member’s room and see that brand new little baby, you see a new part of your life.  You see your friend or family member’s new son or daughter, a new part of your social circle, a new little person that you will come to know and love.
    I’m a nurse.  You know what I see when I look at that same baby?  A patient.  That baby, just like his or her mother, is my patient, and while I will certainly talk to the kiddo while I’m taking her temperature and making her cry with her first shot, I’m not forming emotional attachments to the baby like you and the baby’s parents are.  While some may see it as cold, I view that infant through the objective eyes of a professional.
    Case in point, when I visited a close relative in the hospital and met her baby for the first time, I had to remind myself that I was not her nurse–and it wasn’t my job to watch the monitors (although I admittedly did, purely out of habit!).
    My perspective on my tiny patients isn’t to diminish the significance of their lives; rather, it is for his or her protection.  Because if something bad starts to happen to that baby, what would you rather have me do–freak out like your best friend or react like a professional nurse?
  2. I have a lot of things to do that don’t involve holding the baby. No really, I mean a lot.
    During the course of my shift, I am charting on mom’s contractions and baby’s heart rate and ensuring that those are happy patterns every 15 minutes.  If something goes wrong with either, I am at the bedside to intervene.  That may include changing the rate of medications on the IV pump, giving more fluids, giving oxygen, or sometimes even repositioning mom to make baby happy–even if that takes five coworkers to do because mom is 300lb and has an epidural.
    Speaking of which, if mom has an epidural and all is going well, I’m checking on her level of consciousness, respiratory pattern, anesthesia level, pain rating and a host of other things every 30 minutes.  I’m getting her temperature and emptying her bladder every 2 hours.
    And all that stuff is what I have to do before baby is born.
    After baby arrives, I’ve got vitals, pain and fundal checks (those fun, fun tummy presses for those of you who have delivered in a hospital) on mom every 15 minutes for the first hour, every 30 minutes for the second hour, vitals on baby every 30 minutes for 2 hours, two meds for baby, one med for mom, and a whole ton of charting that has to be done before I can move mom and baby to postpartum.  And that doesn’t even begin to cover teaching mom to breastfeed or doing a recovery from a C-section!
  3. Once baby is here, my work is almost done.
    As an L&D nurse, I only keep mom and baby on my floor for another 2 hours after birth.  This certainly doesn’t even begin to encompass an entire shift of baby holding.  But even if you were to talk to a NICU nurse or a postpartum nurse, they’ll tell you they certainly don’t spend their shifts holding babies.
    Postpartum nurses have 4-6 couplets (moms and babies) to tend to.  That’s 8-12 patients that are fully dependent on them!  Between med passes and breastfeeding assistance and parent education and charting, you probably won’t catch any of them spending their shift baby rocking in the nursery (which is minimally used anymore at most hospitals anyway).  While there certainly are nurses who take a few minutes here and there to rock their smallest patients to sleep if mom is already out, this is a rarity, especially in the 21st century.
    NICU nurses are highly specialized, rendering care to the most fragile little humans on the planet.  Just like myself and postpartum nurses, they especially view their infant charges as patients and keep their carefully trained eyes open for the first hint of trouble.  Many of their patients are so small that they are actually being shielded from external stimuli such as touch to simulate the warm, dark environment of the womb.  And while some of those babies certainly are big enough to hold, the fact that many NICUs have volunteers who come in specifically to hold their babies should tell you that a NICU nurse’s day is filled with much, much more than baby holding.
  4. Labor is hard…on everyone!  Ladies, I’ll take your high fives in the comments.
    Even with an epidural and a great nurse and doc and a wonderful partner and supportive family, labor is tough.  And that’s under the best of circumstances.  How about we look at a more common scenario.
    Let’s say you come in at 5 centimeters with killer contractions.  The anesthesiologist is back in a C-section, your breathing techniques aren’t working anymore, I have to strap a bunch of monitors to your abdomen amidst your contractions and need you to stay seated so I can monitor the baby, but the only thing that helps your pain is walking–but then I can’t see baby’s heartbeat.  Your mother is freaking out at me because I can’t sugar-plum-fairy your pain away, your other relative is taking pictures of you as you cry on the birth ball, and the OB is trying to get ahold of me to let me know that she/he wants you delivered by 1700.  Somehow, an anesthesiologist magically appears, but it’s your unlucky day because the epidural isn’t everything you dreamed of and more, and you can still feel some amount of pain through your epidural (which is normal, but God forbid anyone suggest to a woman these days that labor will still have its painful moments!).  Meanwhile, your baby’s heartbeat is starting to dip in ways that I don’t like, I have a room full of your crazy family, and you’re so caught up in your contractions and your screaming family members that you can barely hear my coaching, which might actually make your labor tolerable until the anesthesiologist comes back to give you a nice extra epidural dose right after this next C-section, assuming you are still pregnant.
    Take any aspect of that scenario.  I see at least one of those situations on every shift, usually more.  There are some shifts that I’d kill to spend a night rocking babies.
    The last few points mostly focused on the circumstances of my job that make my work what it is.  But what about the circumstances that my patients bring in with them?
  5. Not all moms are healthy.
    In fact, a rising number come into pregnancy with serious preexisting conditions.  Obesity, diabetes, heart disease–you name it.  Women with all kinds of health problems get pregnant, and pregnancy is often no walk in the park for those who do begin the race healthy.  Add an already unhealthy mom and you’ve got a stage primed for preeclampsia, gestational diabetes, HELLP syndrome, and a myriad of other conditions and complications that go along with disease processes that not only affect mom but baby, too.
  6. Not all moms stay healthy.
    The truly unfortunate cases are those women who enter pregnancy from a healthy vantage point only to be blindsided by something unforeseen.  They had no risk factors, no predisposing issues, but they got hit with whoppers anyway.
  7. Not all moms care enough to keep themselves healthy.
    These are the cases that infuriate most healthcare workers.  They’re the moms who get pregnant and just don’t want to kick that smoking habit.  Or using crack or heroin.  Or drinking.  Or cutting or overeating or under-eating.
    Or, they’re diagnosed with a serious illness either before or during pregnancy, and they won’t take their medication, follow up with their doctors, or do much of anything to ensure not only their own safety, but the well-being of their unborn child.  It’s heartbreaking and frustrating and ultimately, I as a nurse can do nothing about it other than educate and try to help mom see a better way to live her life.Between the women in any of the categories above, some will stay with us for months prior to delivery.  Some will deliver early.  Some will have emergency C-sections.  Some will become NICU moms.  Some will deliver normally and everything will be fine.  A small number will get seriously sick, and a few will even die.  Some will lose their babies either before or shortly after birth.  Either way, their ailments will not only affect their lives, but the lives of their babies, their families, and all those around them.
  8. Not all babies are wanted.  It isn’t necessarily the norm, but L&D nurses see the full range of the human spectrum.  We see the parents who are ecstatic and have read every book on the planet about parenting.  They’re ready.  They’re beaming.  It’s glorious.
    And then, there are those moms who don’t want anything to do with their baby after he or she is born.  Mom sits in bed withdrawn, numb to the little life in the bassinet beside her.
    I’m not talking about mothers who have postpartum depression or some other condition that prevents them from bonding with their infant.  I’m talking about fully healthy and entirely capable women who just don’t care.
    Neglect is often evident long before mom leaves the hospital.  And the kicker?  There’s not a darn thing any of us can do about it.
  9. Not every parent will treat their baby right.
    In a similar vein as the category above, there are those moms who scream and cuss at their unborn babies and newborns, who have begun the process of ruining them with profanity and abuse and anger.  There are the angry fathers, the disappointed parents, the ones who wanted a girl and not a boy or a boy and not a girl.  They’re the ones who you say a silent prayer as they slip down the hallway–an innocent life disappearing into violent, unloving arms.  They’re the ones you pray don’t end up in the NICU, PICU, or worse.
  10. Sometimes children have children.  I know, I said it.  In an age where Teenage Mom is all the rage, I’ll tell you that from my standpoint, often times, those are sad stories, no matter what the good ol’ TV or the teenage mom’s mom or her sweet little old auntie will tell you.  I know that not every child born to an adolescent will end up in the admittedly fatalistic picture I’m painting, but I also know there are a good many who will, and when you’ve seen your third 16-year-old who has miscarried twice in a year and is now on her third pregnancy because “I just wanna have a baby”, then perhaps you’ll understand my disdain for the culturally rampant lie that would have you believe that teenagers in the USA are ready to be parents.
    These aren’t daytime soaps.  They’re stories about innocence and opportunities lost.  They’re stories about children raising children who will never have the benefit of being raised by an adult, and as a result, will likely struggle to become adults themselves someday.  They’re stories about balancing high school and parenthood, about a child clinging to the tattered remains of a past adolescence as circumstances thrust them into a premature adulthood, often without any real role models to copy.  They’re stories about absent parents and the perpetuation of a cycle that sees children as possessions, not human beings to be treasured and disciplined and brought up.
    And it’s a sad reality that our culture has opted to sensationalize and normalize such behavior instead of exposing it for what it really is–a selfish, dangerous lie.
  11. Especially these days, many people see their children as accessories.
    On the same note as item #10, sometimes even adults are really just children having children.
    I guarantee you, you know someone like this.  They’re the mother who is being induced because she has to have her baby on this specific day so she can still make her hair appointment two days after.  Or she has to have a boy because that’s the color she painted the nursery.  These are the parents who love to talk about their kids like prize trophies, but the instant the children become real little people with needs of their own, the desires of the parents trump the needs of the kids, and suddenly mom’s throwing a tantrum because she doesn’t have time to feed the baby–she’ll be late for girls’ night out!
    Now, I’m certainly not saying that once you’re a parent, you forego any semblance of your own life.  I’m talking about parents who consistently and arrogantly put their own desires above the needs of their children, and when you see it as often as I do, it’s an ugly sight to behold.  It is a disease borne out of a very human urge to think only about me, me, me, and there are few traits more disgusting and misplaced than when found in parents.
  12. Some births don’t go as planned and some are downright traumatic.
    There are few things more heartbreaking to me than to have to tell a mom who is hell-bent on delivering her baby vaginally that it just isn’t going to happen–we must do a C-section.  Or seeing a mom, with no support from her partner, opting to get an epidural when all she wanted was to deliver without pharmacological pain intervention.  Or watching the on-call OB cut an episiotomy without warning or reason on a woman who didn’t want to be cut.  Or watching a traumatic birth take place, knowing that that woman’s sex life and bowel patterns will never be the same.
    Say what you want to about some women who come in with 12-page birth plans, but if it were your birth and your baby, you’d be just as heartbroken if things didn’t go the way you wanted.
    As a nurse, I am your advocate, and when you experience what you perceive as failure or trauma in the process of delivering, you can bet that I feel it as well.
  13. Not all babies are born alive.
    I know that’s a loaded statement, but it’s one that you should think about when you imagine me at work.  Some of my most important contributions to my profession and my patients are when I take care of those parents who have lost their children.
    L&D nurses, despite our usual role in delivering new life, are also present for when babies are born dead.  Moms still labor, contractions still hurt, and babies must be born, even when their lives are over before they begin.
    L&D nurses are present in that process from start to finish.  Often times, it’s the L&D nurse who will look for baby’s heartbeat when mom comes in, telling us she hasn’t felt baby move in a little while.  It’s an L&D nurse who calls the doc, orders the STAT ultrasound, and is there when the parents get the bad news.  L&D nurses admit those patients and are with them and their families throughout labor and all the way through delivery to recovery.  We are the ones who set the tone for the family, provide the keepsakes and photos they will treasure, and try to protect and respect the body and memory of a child that the no one will never get to know.
  14. Not all babies live.  If you thought #13 was as tough as it gets, think again.  L&D nurses are not only there with the parents who deliver stillborn or miscarried children, but also for those who deliver babies who are alive, but will almost certainly die.  Anything from birth defects to prematurity to unknown causes can be the culprit, but it’s only one more aspect of the heartbreaking and frighteningly common theme of loss in obstetrics.
    When that baby is born alive and gasping for air, who will the parents rely on to teach them, to reassure them, to make baby comfortable as he or she slips away or to try to save that life?  How will those precious moments with that little one be remembered?  It is possibly the most difficult aspects of the job.

The points listed above certainly do not comprise an exclusive or complete list of why L&D nursing is difficult; they’re just the most obvious ones to me; the ones that come immediately to mind.  I fully expect to return to this article and edit as needed, either to clarify or augment points listed.

And sure, I could write a whole different article on why I love my job and why it’s so rewarding, but honestly, those are reasons you can probably think of yourself.  They’re things you commonly associate with my work and perhaps things you’ve had the pleasure of experiencing firsthand.  What you need to take away from this is that it takes a certain kind of person to do my job and still walk away at the end of shift feeling fulfilled and happy.  And unless you can take all the wonderful, happy things that come with L&D nursing and accept that with the list above, you’re not cut out to do what I do.

So the bottom line is that L&D nursing is still nursing.  It still is an art and science that deals with human beings, and as long as that is the case, it will include pieces of all the heartache and pain contained in the span of a human lifetime.  Indeed, if pregnancy and childbirth have the potential to be some of the brightest and happiest events in a person’s life, they also have great potential to be the darkest and saddest.

In short, if you’re looking for the happiest job on earth, don’t look to L&D.  Heck, please don’t even look in nursing.

But I hear Disney’s still hiring.